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Domicile Affidavit – Residency Statement
INSTRUCTIONS: If you will be under the age of 19 or claimed as a dependent, at the start of semester, columns “A” and
“B” are required. The student fills out column “A” and the parent or legal guardian fills out column “B”. Complete the
information in ink, leaving no blanks. Students who do not complete the form or leave information blank may be classified
as a non-resident for tuition purposes. Documentation is required as indicated below or when requested by the College.
1. Full Legal Name (Last, First, Middle)
2. For what term are you seeking classification as a resident?
Fall Spring
3. CCC Student ID Number
@__ __ __ __ __ __ __ __ or Comet ID:
4. Social Security Number*
____ ____ ____ - ____ ____ - ____ ____ ____ ____
5. I choose not to disclose my social security number*
Signature:
6. Home Phone Number
(
7. Birthdate and Age
Month__________ Day_______ Year_________ Age _________
8. Are you seeking admission under the Wester